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The Patient's Story

Mr G is an unmarried, 47-year-old truck driver, living in Oregon. After an industrial accident, he experienced persistent pain in his arm. When weakness developed, his primary care physician, Dr J, referred him to a neurologist, who diagnosed him as having amyotrophic lateral sclerosis (ALS).

Mr G's disease progressed with unexpected speed and was not responsive to any medical interventions. Mr G had a close relationship with Dr J and openly discussed his wishes for end-of-life care. He and Dr J completed a Physician Orders for Life Sustaining Treatment (POLST) form, reflecting Mr G's desire to receive no life-sustaining treatments such as cardiopulmonary resuscitation (CPR), tube feeding, or mechanical ventilation. He also mentioned to Dr J that he might consider physician-assisted suicide (PAS) as he neared death.

Within months of diagnosis, Mr G lost the ability to ambulate and care for himself. Because he had no family caregivers, he was transferred to a skilled nursing facility, where he continued to reside. Dr J did not treat patients at this facility, so Mr G's medical care was transferred to Dr R, the facility's house physician.

In the 6 months that followed, Mr G's disease progressed rapidly. When he began having difficulty speaking and swallowing and was nearing death, Mr G asked Dr R to help him end his life. Dr R did not respond directly to the request and did not explore it further. Instead, he referred Mr G to the nursing home hospice program. Mr G reported to the hospice social worker that he had asked Dr R for PAS. When the social worker contacted Dr R to confirm the request, Dr R became angry at her for discussing PAS with Mr G. Because of his moral opposition to PAS, Dr R chose to discontinue caring for Mr G. Dr L, the hospice medical director, then became Mr G's physician.

Perspectives

Mr G consented to be interviewed by a Perspectives editor but had become too weak to participate before the scheduled interview. A Perspectives editor interviewed the hospice social worker, Ms T, who referred to case notes to provide Mr G's perspective. The Perspectives editor also interviewed Drs R and L.

DR R:We didn't really talk about assisted suicide. He brought it up to me several months ago. He pretty much stopped me in the hall and wanted to know what my thoughts were about it and if I was prepared to help him.

DR L:He had very rapidly progressive ALS. For the typical course, prognosis after diagnosis is often 3 to 5 years. He was diagnosed last December…but rather quickly, within even a couple of months, he was having trouble walking and ended up being transferred to a nursing home, where he spent the remainder of his life. By the time I saw him [about 10 months after ...